People with dementia are at an increased risk for hot water burns. They may confuse the hot and cold water handles, and they may forget how to blend the hot and cold water to a safe temperature. Or there simply may be a sudden surge of hot water when someone nearby flushes the toilet.
Homes and apartments have water heaters commonly set at 140° to 150° F – temperatures at which a severe burn can occur within 1 to 5 seconds. However, lower water heater temperatures tend to increase bacterial growth. For example, 120° F has been the standard recommended water heater temperature for reducing hot water scalding risk. But individuals with compromised health and those undergoing chemotherapy are at increased risk for Legionnaires Disease with water stored at these lower temperatures.
It’s important that you assess scald risk for both yourself and your care receiver. We’ve sorted through a wide body of literature to help you choose a scald safety strategy to meet your needs.
Use Visual Cues
For some people, especially those in the early and middle stages of dementia, a visual cue helps them to remember which faucet handle is for hot water versus cold. Some people may respond better to text or color. Try placing a “HOT” sign, in large red bold letters, directly above the hot water handle. Or, depending on the type of faucet handle, apply red waterproof electrical tape, available at home supply and hardware stores. If the person disapproves, some caregivers discretely tell them it’s for the grandchildren’s safety.
Check Water Temperature
Water that is too cool or too hot can trigger agitation – and extremely hot water can cause burns, so you want to make sure the water is at a comfortable temperature. Buy a water thermometer and check the water before the person bathes or showers. Water temperature around 98° to 100° is comfortable for most older adults.
Use Anti-Scald Valves
A handheld showerhead that has a built-in anti-scald device protects against burns by reducing scalding water to a trickle but is best used with a caregiver present as the water often needs to be manually remixed to the proper temperature.
Lower Water Heater Temperature, With Caution
120° F has been the standard recommended water heater temperature for reducing hot water scalding risk. A severe full thickness burn can still occur at 120° F but it takes 5 minutes, allowing the person and caregiver more time to react and remove the person from the hot water.
Individuals with compromised health and those undergoing chemotherapy are at increased risk for Legionnaires Disease with water stored at 120° F – so a better solution is an anti-scald valve. But it’s important that you assess the person’s scald risk and overall safety and make the decision that’s right for them – and for you, too, if you’re living with the person you care for.
Scald Prevention for People with Dementia
Person’s with dementia are at an increased risk for hot water burns as memory loss and lack of judgment increase unsafe behaviors. The person may confuse the hot and cold water handles or forget how to blend the hot and cold water to a safe temperature. Age-related sensory loss and mobility impairments also decrease the person’s ability to move out of the way when water is scalding. And older skin is thinner and more susceptible to burns.
Lower Hot Water Heater Temperature Can Cause Problems
Most homes and apartments have water heaters set at 140°F or above; a severe burn can occur in 5 seconds at 140º F or in 1 second at 150º F. But lower water heater temperatures can increase bacterial growth. For example, 120°F has been the standard recommended water heater temperature for reducing hot water scalding risk.
This lower temperature, however, can increase health risks, as bacteria can thrive at temperatures below 140º F, especially in electric heaters. Older adults with weakened immune systems are at increased risk for Legionella bacteria (which causes pneumonia) when water heater temperatures are reduced.
As Legionnaire disease is primarily spread through droplets, the shower and bath area are key risk areas. Many factors affect how much Legionella will multiply and whether they create a health risk, such as water temperature and mineral content, water heater type or design and health of people in the household.
To reduce both the risk of Legionnaire’s disease and scalds, many experts recommend keeping the hot water heater set at higher temperatures (140°F+) and delivering safer, temperate water (110° – 120°) at the tap through the use of anti-scald valves. A severe burn can still occur at 120°F, but it takes 5 minutes, allowing the person and caregiver more time to react.
There are two basic types of anti-scald valves:
- DIY screw-on valves that reduce scalding water to a trickle at the tap
- Plumber installed valves that adjust the water temperature in the pipe before it flows from the tap (single faucets, specific rooms or the entire house).
Anti-Scald Valves (DIY)
Temperature Activated Flow Reduction Valves (TAFR) like these are available as either separate valves that you screw onto existing faucets and showerheads or as replacement fixtures (tub spouts, showerheads, or handheld showerheads) with integral anti-scald valves.
How do the DIY Anti-Scald Valves Work
An internal metal alloy expands when the water temperature reaches 115 – 120º, reducing the water flow to a trickle. For the water to flow again, the hot water knob must be turned off while the cold water knob is kept on, and then the water must be remixed again to a safe temperature.
PROS
- Especially helpful for apartment dwellers who don’t have access to the hot water heater or pipes in the wall.
- Inexpensive.
- Fairly easy to install, with the exception of the tub spout, as the old spout may be difficult to remove.
- The temperature in the water heater can be maintained at higher temperatures to avoid bacterial risk.
CONS
- Maximum hot water temperature is pre-set by the manufacturer
- The device may turn the water off during activity (e.g., dishwashing) at temperatures user finds acceptable
- Hot and cold water must be manually remixed after the device reduces the flow to a trickle or the water will not flow
- May malfunction over time due to local water conditions
Because persons with dementia may be unable to operate the faucet with the anti-scald valve installed, it may be best used with a live-in caregiver, given that the hot and cold water must be properly mixed or the water will not flow. Devices should be checked often to make sure they’re working properly.
Anti-Scald Device (DIY Screw-On Type)
This screw-on valve attaches directly to the faucet to control hot water temperature. An internal metal alloy expands when water exceeds 117º F, reducing the water flow to a trickle.
PROS
- Allows storage of hot water in the hot water tank at the temperature (140º F) necessary to reduce the risk of bacterial growth
- Especially helpful for apartment dwellers who do not have access to the hot water heater
- Easy-to-Install
CONS
- Maximum hot water temperature is pre-set by the manufacturer.
- The device may turn the water off while washing dishes at temperatures user finds acceptable.
- When the device reduces water to a trickle, the hot and cold water have to be manually remixed or the water will not flow. This may be confusing to the care recipient.
If you have hard water, the device could get plugged up with mineral deposits, as our bathroom sink valve did, rendering it ineffective. We were able to take the device apart and take out the hardened calcium deposits, but it took just a few weeks before we had to take it apart again. (So we installed an under-the-sink valve on that bathroom sink). We’ve been using the same valve for over a year on our kitchen sink faucet with no problem.
Because persons with dementia may be unable to operate the faucet with the device installed, it may be best used with a live-in caregiver, given that the hot and cold water must be properly mixed if the water flow is reduced or the water will not come back on.
You need to check often to make sure the valve is still working.
Anti-Scald Mixing Valves For Single Faucets (Plumber Installed)
These point-of-use “thermostatic mixing” valves are installed directly on the pipes at sinks and bathing areas, mixing cool and hot water in the pipe before the water flows out of the faucet. Some models allow the consumer to adjust the water temperature after installation, but offer a safety cap to protect against unwanted meddling; other models require a plumber to do the adjustment.
PROS
- These are excellent for individuals living alone (no need to remix hot and cold water as in the TARFS shut-off model) and for apartment dwellers without access to the water heater.
- The valve mixes cold and hot water to a safe pre-set maximum temperature before it flows out of the faucet.
- The temperature in the water heater can be maintained at higher temperatures to avoid bacterial risk. You’ll need to tell plumber the maximum hot water temperature you’d like at the tap. Consider 110F, the maximum temperature allowed in nursing homes.
CONS
- Must be installed by a licensed technician
- Additional expense (valves $75+ plus approximately ½ to 1 hour of labor)
Anti-Scald Mixing Valves For Entire Rooms or Whole House (Plumber Installed)
These mixing valves or tempering valves are installed outside the hot water tank and mix cool and hot water so the water can be delivered at a safer temperature (110° to 120° degrees F) to individual faucets and shower heads, for one room only or the whole house.
The mixing valves come in a variety of models for different plumbing systems, water heaters, and house sizes. Depending on the size of your home, you may need extra valves at individual taps, especially in the bathing area. Consult a plumber for more information.
PROS
- Excellent anti-scald control for individuals living in their own home
- Cold and hot water mixed to a safe pre-set maximum temperature before it flows out of the faucet
- The temperature in the water heater can be maintained at higher temperatures to avoid bacterial risk. You’ll need to tell the plumber the maximum hot water temperature at the tap. Consider 110° F, the maximum temperature allowed in nursing homes.
CONS
- Must be installed by a licensed technician
- Additional expense (cost of valve plus labor)
